Damage Control Resuscitation.

Sunday, October 26, 2014 2

Damage Control ResuscitationBy

DR. Mahmoud Abdulkareem

M.S {Cairo} , FRCS {Glasgow}

Consultant Surgeon,

King Fahad Specialist Hospital


History of Trauma Resuscitation

About fifty years ago; there was Little or no systematic resuscitation after a civilian injury.


“the neglected disease of modern society.”

THE NEED FOR TRAUMA SYSTEMS—HISTORY …. cont.

National Research Council: Accidental Death and Disability: The Neglected Disease of Modern

Society. Washington, DC: U.S. Government Printing Office, 1966.


MODERN TRAUMA SYSTEM

DEVELOPMENT …. cont.

By 1975, Germany had established a nationwide trauma system, so that no patient was more than 15–20 minutes from one of these regional canters.


Injury prevention

has become an essential focus for all trauma systems

prevention

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Trauma system

The true value of a trauma system is derived from the seamless transition between each phase of care


Trauma Management: Golden Hour

Golden HourTime to reach operating room (or other definitive treatment)Patients in their Golden Hour must Be recognized quickly Have only immediate life threats managedBe transported to an appropriate facilitySurvival depends on assessment skillsGood assessment results fromAn organized approachClearly defined prioritiesUnderstanding available resources


Prehospital Care ….con. The goal is to get the right patient to the

right hospital at the

right time for definitive care


Advanced life support is provided[by an organized trauma team]

Early hospital phase:


Trauma TeamDefinition

The trauma team is an organized group of professionals who perform initial assessment and resuscitation of critically injured patients. Team composition, level of response, and responsibilities of each member are institution-specific. Personnel are outlined as follows:

1. Trauma surgeon—a general surgeon with demonstrated training and interest in trauma care. In designated trauma centers, the trauma surgeon typically functions as the trauma team leader.

2. Emergency medicine physician—in many hospitals, the emergency medicine physician functions as the trauma team leader depending on the perceived severity of injuries. Ideally, these physicians have Advanced Trauma Life Support (ATLS) certification.

3. Anesthesiologist—a physician with special skills in airway management, sedation, and analgesia. In many trauma centers, this role may be fulfilled by a certified registered nurse anesthetist

4. Trauma nurses—emergency department nurses with specialized training and demonstrated interest in trauma care.

5. Resident physicians—residents in emergency medicine or surgery and trauma fellows may assume active roles in the trauma team. In Level I and II trauma centers, senior surgical residents and trauma fellows may function as trauma team leaders.

6. Respiratory therapist—therapist available to assist in the evaluation and management of the patient's respiratory status.

7. Radiology technicians—technicians available to obtain x-rays as indicated by the initial assessment and secondary survey.

8. Surgical subspecialists—although not typically involved in the initial assessment, surgical consultants (e.g., orthopedic surgeons, neurosurgeons) are vital members of the trauma team.

9. Other personnel—the trauma team may also include OR nurses, laboratory technicians, ECG technicians, chaplains, social workers, transport personnel, and case managers.



Original article

Impact of a multifunctional image-guided therapy suiteon emergency multiple trauma care

T. Gross1, P. Messmer1,7, F. Amsler5, I. Fu¨ glistaler-Montali1, M. Zu¨ rcher2, R. W. Hu¨ gli1,6,P. Regazzoni1,3 and A. L. Jacob1,4

British Journal of Surgery 2010; 97: 118–127Conclusion: Implementation of a MIGTS in the emergency treatment of multiple trauma significantly

accelerated the procedure and reduced the number of in-hospital transports.



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Posttraumatic hemorrhage is responsible for one of the leading causes of preventable

human deaths worldwide.

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INTRODUCTIONDuring the last two decades, advances in pre-hospital care and the adoption of the “scoop and run” philosophy has resulted in the arrival of more severely injured patients who typically might have died in the field or en route to the hospital.


Standard surgical practice

Standard surgical practice (early total care. The best operation for a patient is one, definitive procedure

The first chance of any surgical intervention is the best chance for any definitive repair or reconstruction

ER

ER→OR→ICU

OR ICU

What has been going on??

The conventional sequence of the management of trauma surgery was to bring the patient to the operating room after initial resuscitation and then to operate for complete repair of the injuries. Subsequently, these patients were sent to the intensive care unit where a good number of them succumbed due to metabolic derangement of the body.

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The outcome…..

“The operation was a success but the

patient died anyway”–

Anonymous

DCS 2

In severe trauma patients a triad of

hypothermia, metabolic acidosis, and

coagulopathy rapidly established. This so

called " vicious cycle of metabolic failure " is

irreversible as long as patient is in the

operating room with the abdomen open

during a prolonged procedure.

But,…… why?!

" vicious cycle of metabolic failure "

Damage control is a naval term first used during World War II to describe emergency measures for control of flooding that threatens to sink a ship. A range of simple procedures may be used, but the central goal is to ensure survival of the ship until it reaches a port where definitive repairs can be safely performed.

Damage control


Damage Control !

Damage Control – Philosophy

Damage control is based on the principal that outcome after major trauma is determined by the physiological limits of the patient , rather than by the effort of anatomical restoration by the surgeon.

Applying the same philosophy

To save the patients in extremis, surgery should be abbreviated . only immediately life threatening injuries should be attended and repaired, while other injuries should be temporized and repaired definitively when the patient is more stable. The best place for a severely and multiply injured patient is in the intensive care unit.

Damage Control – Philosophy

The damage control concept places surgery as an integral part of the resuscitative process, rather than an end in itself.

The term “Damage control”

Rotondo and Schwab in 1992 coined the term “damage control” and outlined a three phased approach:

Part one (DC I) consists of immediate exploratory laparotomywith control of bleeding and contamination, abdominal packing and abbreviated wound closure.

Part two (DC II) consists of the ICU resuscitation; immediate endpoints include physiological and biochemical stabilization. A tertiary exam should be performed at this time to identify all injuries.

Part three (DC III) consists of re-exploration and definitive repair of all injuries.


Damage Control Surgery

The later damage control is applied, the less successful the outcome.

When to employ damage controlο Use damage control in patients who are present with or at risk for developing:♦ Multiple life-threatening injuries.♦ Acidosis (pH < 7.2).♦ Hypothermia (temp < 34°C).♦ Hypotension and shock on presentation.♦ Combined hollow viscus and vascular or vascularized organ injury.♦ Coagulopathy (PT > 19 sec and/or PTT > 60 sec).

♦ Mass casualty situation.ο

When to employ damage control

When to employ damage control


REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta), together with a pelvic binder, for control of hemorrhage in ER

REBOA (Resuscitative EndovascularBalloon Occlusion of the Aorta)


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Phase 1 of damage control includes 5 distinct steps:1. Control of hemorrhage.

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intra-arterial shunt in left common iliac artery

Phase 1 of damage control includes 5 distinct steps:1. Control of hemorrhage

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In this case, especially with colonic injuries, or multiple small bowel lesions, it is wiser to resect non-viable bowel and close the ends, leaving them in the abdomen for anastomosis at the second procedure. The linear stapler is useful to achieve this, but bowel ends may be closed with running suture or even umbilical tapes. Ileostomies or colostomies should preferably not be performed in a damage control setting, especially if the abdomen is to be left open, as control of spillage is almost impossible.

Phase 1 of damage control includes 5 distinct steps:

2. Control of contamination.

Phase 1 of damage control includes 5 distinct steps:3- EXPLORATION TO R/O SIGNIFICANT INJURY

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Phase 1 of damage control includes 5 distinct steps:4-Therapuitic packing

Directly to the IS- jointPacking of the fractured areaLaparotomy pads into the true pelvis

Extraperitoneal Packing


Phase 1 of damage control includes 5 distinct steps:5- Temporary abdominal closure .

Left lateral thoracotomy with towel clip closure of damage-control celiotomy. Courtesy of Pedro Gustavo R. Teixeira, Trauma Surgeon, Brazil, The Trauma Imagebank.

Methods of Temporary abdominal closure

Bogota bag


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Approach :

1. Permissive Hypotension

2. Limited Crystalloid

3. Transfuse Blood Components in Equal Ratios

PRBC’s / FFP / Platelets

Source Control of Bleeding

Damage Control Resuscitation in Combination With Damage

Control Laparotomy : A Survival Advantage

J Trauma. 2010;69: 46–52


Damage control resuscitation (DCR) represents the natural

evolution of the initial concept of damage control surgery.

Permissive Hypotension in Trauma Resus.

IV fluids in hypovolemic shock:

• No survival, some mortality

Theories on IVF in trauma:

1. BP dislodges clots

2. BP = bleeding

3.IVF hemodilutes clotting factors

Duchesne JC et al. Damage Control Resuscitation: From Emergency Department to the Operating Room. The Amer Surgeon. 2011; 77: 201-206.

Permissive Hypotension Limits• SBP 90 (MAP 50 – 60 mmHg):

• Ideal permissive hypotension < 90 min.

• Severe damage when > 120 min.

• It is important to remember that permissive hypotension is a temporizing measure to improve outcomes until the source of bleeding is controlled.

Li T, et al. Ideal Permissive Hypotension to Resuscitate Uncontrolled Hemorrhagic Shock and the Tolerance Time in Rats. Anesthesiology. 2011; 114 (1): 111-119.

Contraindication of Permissive Hypotension

• traumatic brain injuries, because adequate perfusion pressure is crucial to ensure tissue oxygenation of the central nervous system.

• Preexisting conditions such as hypertension, angina pectoris, coronary disease, and carotid stenosis may also lead to severe cardiovascular dysfunction when trauma patients are hypotensive. These conditions are common mainly in the elderly (>65 years old), but also occur in other age groups because of occult disease.




The concept of giving plasma and platelets early along with red cells in an attempt to closely approximate whole blood makes a lot of sense. In fact, when we reviewed blood usage at the Shock Trauma Center in the year 2000, massively transfused patients ultimately received a unit of plasma for every unit of blood that was transfused. It made a lot of sense that giving FFP earlier would be beneficial.

Hemostatic Resuscitation

Hemostatic resuscitation, which promotes balancedblood product transfusion ratios while minimizing crystalloid infusion, improves outcome in critically injured, coagulopathic adults.


Hemostatic resuscitation is a transfusion strategy that targets coagulopathy with early blood product administration.

The new resuscitative paradigm has become to allow a systolic blood pressure to be around 80 mmHg, to limit crystalloid resuscitation, and use blood, FFP and platelets in a one to one to one ratio.





DCR, which in part aims to reproduce whole blood resuscitation via the use of approximately 1:1:1 ratios of red blood cells (RBCs), plasma, and platelets, has become the standard of care for the transfusion management of patients with severe hemorrhage. This approach, however, comes with a potential cost: the use of a greater quantities of plasma and platelets.

Disclaiming and Criticizing Hemostatic Resuscitation with 1:1:1 ratios

CAGS AND ACS EVIDENCE BASED REVIEWS IN SURGERY. 50Is early transfusion of plasma and platelets in higher ratios associated with decreased in-hospital mortality in bleeding patients?

J can chir, Vol. 57, No 5, octobre 2014 © 2014 Association médicale canadienne

While the PROMMTT study adds further evidence to support transfusions with higher plasma :RBC transfusions, further studies are needed, especially regarding how to efficiently identify the patients who will benefit from early administration of the therapy.



Recent studies have shown that nearly 25% of trauma patients

present with a clinically significant coagulopathy upon arrival

in the emergency department which affects their overall

outcome.4 Interestingly, this early coagulopathy occurred

before any significant consumption or fluid administration and

in the absence of a relevant acidaemia or hypothermia.

Br. J. Anaesth. (2010) 105 (2): 103-105.

Acute Traumatic Coagulopathy




Recognized in patients with significant tissue injury and hypotension

Distinct from iatrogenic coagulopathy after trauma

Dilutional coagulopathy

Present prior to resuscitation in rapidly evacuated severe trauma

Mortality rate increased 4x

Modulated through protein C activation







The anticoagulant thrombomodulin protein C pathway is overtly

activated, resulting in reduced pro-coagulatory potential and

increased fibrinolytic activity. Once protein C is activated through a

thrombin–thrombotic-dependent reaction, activated protein C

(aPC) exerts its profound anticoagulant effects by irreversibly

inactivating factors Va and VIIIa. In addition to its direct inhibition

of fibrin formation, aPC causes resolution of formed clots by

stopping the inhibition of fibrinolysis by direct inhibition of

plasminogen activator inhibitor .



Hemostasis is a complex physiologic process involving many constituents that act in symphony to form a clot. Conventional coagulation tests, such as prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen concentration, and platelet count, measure only a fraction of this process. Moreover, these tests sometimes lack accuracy in trauma settings.

Hemostasis





In recent years, viscoelastic hemostatic assays (VHA), including thrombelastography (TEG) and thrombelastometry, have been demonstrated to be ideal methods of monitoring coagulation function in trauma patients . Furthermore, several studies have suggested the potential of VHA tests to guide component blood transfusion in a variety of patient groups . In particular, a recent study by Kashuk et al. showed that goal-directed transfusion based on rapid TEG was useful in managing trauma-induced coagulopathy, with the potential to reduce blood product administration in trauma patients.

Viscoelastic Hemostatic Assays (VHA),

Specifically, TEG depicts the following four stages of clot formation: (1) initiation, (2) amplification, (3) propagation, and (4) termination through fibrinolysis. This is accomplished by placing a 0.36 mL aliquot of citrated whole blood sample into a Kaolin coated (“standard”) TEG cup that has been pre-warmed to 37°C. A pin, attached by a wire to a transducer, is then suspended into the sample. The cup rotates around the pin within the TEG autoanalyzer at an angle of 4.45 degrees every 10 seconds. As the clot forms, the pin and the cup are ultimately joined by the formation of the fibrin and platelet clot. This causes the pin and the cup to rotate together, with the resultant change in tension detected by the transducer. A graphical output is then plotted as a change in tension (measured in millimeters on the y axis) versus time (measured in minutes on the x-axis).The four key parameters of the TEG tracing are the: (1) r value (reaction time to clot formation), (2) α (alpha) angle – rate of clot formation, (3) MA (maximum amplitude – maximum strength of clot), and (4) LY30 (percent clot lysis 30 minutes after the MA).

Viscoelastic Hemostatic Assays (VHA),




Normal TEG tracing (in black) resembles a wide flat (non-functional) shovel with a short handle. The superimposed “shovel” (in red) demonstrates a tracing with a prolonged r, flat α angle, small MA, and increased LY 30, indicative of a systemic coagulopathy with fibrinolysis.

Abnormal TEM Tracings, Interventions




Antifibrinolytic componds• Tranexamic acid (TXA)– Binds to plasminogen– Interferes with the conversion to plasmin– Inhibits fibrinolysis• Diminishes blood loss.

How and When to Use TXA for Trauma PatientsIndications:

Adults with acute traumatic injury leading to significant hemorrhage and requiring blood transfusion.May be beneficial in trauma patients with significant hemorrhage and evidence of hyperfibrinolysis on rotational electrothromboelastometry (ROTEM).Should only be given less than 3 hours from the time of injury.

Dosing: 1 gram IV bolus over 10 minutes, followed by 1 gram continuous IV infusion over 8 hours.









.وآخر دعوانا أن الحمد هلل رب العالمين

10/26/2014

Damage Control Resuscitation.

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